Procedural Simulations and Reflective Practice: Meeting the Need

The Importance of Reflection on Practice for Learning

Effective reflection on practice emphasizes both questioning and investigating one's practice toward the goal of better understanding as well as improving performance. For professionals, reflection on practice can help to maintain one's professional health and competence and the ability to engage in professional judgment through developing this ability through practice. Experience alone is not sufficient for learning, reflection on experience is essential. Reflection challenges professionals to broaden perspectives on commonly encountered as well as novel scenarios. ² Expertise is increased through developing the ability to recognize how past experience relates to newly encountered situations. ³ As such, the quality as well as quantity of time spent practicing and developing expertise by reflecting on one's practice in applicable contexts influences the development of expertise. In particular, reflecting on and adapting one's cognitive processes related to the domain of practice and mentoring or support in this process have been found to facilitate change in professional practices.^4,5

For learners, reflecting on decisions with a more knowledgeable colleague or mentor can facilitate the process of self-assessment and change. ⁶ This facilitates what Schön describes as “reflection-on-action,” in which a person has the opportunity and ability to frame and reframe a problem encountered in practice to reflect on alternate approaches or decisions that may have been fruitful in that situation. ⁷ Reflection on failed approaches can be a tool to facilitate learning and transform past failures into future successes. ⁸ Reflection is important to alleviate poor performance by allowing learners to self-identify goals for improvement. ⁹ Reflection has been found to enhance professional development ¹⁰ in fields such as teacher training and military tactics. However, reflection is sometimes more of a descriptive than a prescriptive notion, ¹¹ which is why it is important to define reflection on practice in medical education.

Background on Current Roles for Simulation in Medical Education

Simulators can be used to teach technical and procedural skills^21,22 and can also be used to assess both gross and fine psychomotor skills.^23,24 They can be used to assess cognitive and decision-making skills ²⁵ as well as improve nontechnical skills, such as leadership and communication. ²⁶ Simulations can be used to simulate events, such as traumas or natural disasters. They can also simulate operative cases and bedside procedures, or other clinical decision-making environments. ²⁷ Simulations can be used to practice clinical skills both individually and as a team ²⁸ and have been found to positively impact clinical competence.^29,30 With all of these scenarios, the focus of simulation is often learners who are novice to a clinical situation, skill, or way of thinking. However, imparting basic technical and procedural knowledge is only a small part of medical education. Decision-making, critical thinking, and attitude related to problem situations are highly important and are gaining increasing attention. ¹⁵ Research on learning in complex environments suggests that reflection on practice can address many of the necessary learning objectives in medicine and surgery. Reflection on practice can also facilitate learning throughout one's life as a professional by allowing the opportunity to review individual choices and available options. In particular, simulation can be used to reduce error in complex, unpredictable situations by allowing a safe, but meaningful, context for reflection. This is often accomplished through the use of cognitive simulation. ³¹

Simulation for Reflection on Practice

Reflection can inform change and learning when working with simulations. Simulation environments can give clinicians freedom to examine and critique their decisions and to consider more possibilities than those that were initially apparent in the moment. ³⁸ They can allow for a reframing of the problem to consider it from different perspectives and create self-directed learners. ²¹ Simulators can be used to match a previously similar-presented problem from memory or to create a hypothetical situation based on past experience. These instances facilitate the development of surgical expertise. ³⁹ Simulations can also allow for a distancing function to assist with self-reflection. Since errors in practice can be difficult for the surgeon, procedural simulation allows for reflection on potential errors or decisions, of which one is unsure. Procedural simulation allows for reflection on cases and decisions to occur in a safe environment that gives leeway for considering options and getting the opinion of others that allows one to both further knowledge and become a better practitioner. Thus, no matter how good the simulation, if reflection is not taking place, optimal learning is not being achieved. ⁴⁰

One additional benefit to the use of simulators for reflection is that the simulator provides a concrete platform for reflection, helping to ground the reflective process. That is, learners do not have to rely solely on memory—they can reflect on previous actions while performing the action because they are in an environment, in which there is no risk to a patient. Perhaps, in addition to reflection on action (what I have done) and reflection in action (what I need to do), ⁷ there is also reflection through action (what I am doing) with a focus on how this relates to future practice. Procedural simulations are an ideal platform for reflection through action.

Encouraging Reflection on Practice When Learning with Simulations

How can we encourage reflection on practice when working with simulations? Certainly, in medical training and continuing medical education, the value of reflection on practice for physicians is gaining more focus and now becoming more appreciated. ³⁸ Early introduction to the reflective approach is advantageous, especially when paired with simulation. ⁴⁰ However, support is needed to facilitate reflective practice as many learners and practitioners do not automatically engage in this process. The literature describes at least three types of people: nonreflectors, reflectors, and critical reflectors. Nonreflectors do not critically appraise their thoughts or ideas. They may talk about topics or situations relevant to their practice, but they do not attempt to appraise their skill or knowledge in these areas. Reflectors give indications of their thinking process and evaluate their current knowledge around a topic or situation as they work toward a deeper understanding. Critical reflection takes reflection one step further in that learners actively work to adopt a new perspective or way of doing something based on the results of their reflection and their current state of knowledge or practice. ⁴¹ The goal is to facilitate critical reflection.

Engaging in critical reflection can be done around simulation, particularly if the environment around the simulation is designed in such a way as to support reflection on practice. For example, the combination of simulation and multimedia resources designed to support learning and reflection have also been successful in helping to facilitate self-directed learning. ⁴² Procedural simulation environments should be designed in such a way as to increase practice of and motivation to immediately reflect on performance. ⁴ This can be done with things such as performance metrics that offer immediate feedback. ⁴³ Nevertheless, experience with simulation and performance feedback alone is not sufficient. One needs to make use of this experience for change to occur. Therefore, curricula around procedural simulation should encourage and motivate the learner to reflect on practice. One way to accomplish this would be through scaffolding or support of the learning process by instructors by asking reflection questions or for explanation of reasoning behind decisions or prompting to think about how the case relates to other cases that have been done. To teach reflection skills and reap the learning benefits of reflective learning with simulation, educators must be prepared to define what reflection should look like and what the learning goals of reflective practice are. Learners will generally require some instruction on how to be reflective on their practice as well as how to create a plan for change based on their experience. To this end, the simulation environment should be emphasized as a safe space for reflecting on reasons for both successes and failures and how the lessons learned should inform future practice. ⁴⁴

Conclusions

Studies suggest that simulation may be able to replace clinical time for learning in some contexts without compromising the development of clinical competencies. ⁴⁵ Simulators and simulation environments will require greater depth in terms of the ways clinical and procedural skills are taught, cultivated, and enhanced if they are going to adequately allow for the teaching and practice of skills, particularly those requiring further learning opportunities due to the loss of clinical exposure. ⁴⁶ Awareness and reflective practice are encouraged for learning medical practice as well as reducing cognitive and diagnostic errors in both those studying medicine and practicing physicians. ⁴⁷ Reflection guidelines and feedback on reflection can help to improve reflective practice and ability. ⁴⁸ Procedural simulation can help with this by allowing a safe, yet, relevant venue for reflection at all levels of practice.